PFD report

Valmai Ann WEST · Prevention of Future Deaths report

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Issued 13 Jul 2021•Gwent

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Failure to perform patient observations at the required frequency
    Part of recurring concern: Unreliable patient observation arrangements
  2. Inadequate staffing levels for the full range of Emergency Department duties
    Part of recurring concern: Insufficient emergency-department staffing capacity for safe patient carePart of recurring concern: Insufficient medical staffing capacity for timely patient care
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. Action

    Undertake a review of Emergency Department medical staffing alongside the nurse staffing review.

    Stated by Aneurin Bevan University LHBStated in progressThe respondent said that this action was in progress when they made their response on 15 July 2021.
  2. Action

    Complete a review of Emergency Department nurse staffing levels following the Regulation 28 Report.

    Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 15 July 2021.
  3. Action

    Complete an in-depth review of Emergency Department nurse staffing levels at Grange University Hospital, considering increased demand and relevant staffing guidance.

    Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 15 July 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Nurse staffing levels were adequate and did not prevent neurological observations.

    Stated by Aneurin Bevan University LHBDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to perform patient observations at the required frequency

Wider context from the report

“During the course of the inquest, consideration was given to the clinical decisions made in the Emergency Department of the Royal Gwent Hospital. I concluded that there was no evidence that Mrs West was displaying signs that would alert the staff to a possible intracranial bleed. However in evidence Dr ████████ Consultant in Emergency Medicine, acknowledged that the staff had not followed hospital protocol or the NICE guidance in relation to the frequency with which observations should be performed. Dr ████████ assessment of the situation was that this was probably caused by inadequate staff numbers to undertake the full range of duties required. She further stated that this is a frequent and ongoing problem in the Emergency Department. Whilst this did not influence the outcome for Mrs West I am concerned that this may put the lives of future patients at risk. ”

Is this part of a recurring concern?

Yes — Unreliable patient observation arrangements.

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Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Inadequate staffing levels for the full range of Emergency Department duties

Wider context from the report

“During the course of the inquest, consideration was given to the clinical decisions made in the Emergency Department of the Royal Gwent Hospital. I concluded that there was no evidence that Mrs West was displaying signs that would alert the staff to a possible intracranial bleed. However in evidence Dr ████████ Consultant in Emergency Medicine, acknowledged that the staff had not followed hospital protocol or the NICE guidance in relation to the frequency with which observations should be performed. Dr ████████ assessment of the situation was that this was probably caused by inadequate staff numbers to undertake the full range of duties required. She further stated that this is a frequent and ongoing problem in the Emergency Department. Whilst this did not influence the outcome for Mrs West I am concerned that this may put the lives of future patients at risk. ”

Is this part of a recurring concern?

Yes — Insufficient emergency-department staffing capacity for safe patient care; Insufficient medical staffing capacity for timely patient care.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Undertake a review of Emergency Department medical staffing alongside the nurse staffing review.

Verbatim wording from the response

“Senior Nurse Manager for ED and the Assistant Head of Nursing, supported by the Deputy Director of Nursing. The assessment is based on RCN Guidance, RCEM Guidance, Nurse Staffing Levels (Wales) Act 2016 and, importantly, professional judgement. A similar review of medical staffing is also being undertaken.”

Source location

2021-0239-Response-from-Aneurin-Bevan-University-Health-Board_Published
Page 2 · response
Published 15 July 2021

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Complete a review of Emergency Department nurse staffing levels following the Regulation 28 Report.

Verbatim wording from the response

“Following receipt of the Regulation 28 Report a review of the nurse staffing levels was undertaken by the Senior Nurse Manager of the Emergency Department. I can confirm nurse staffing levels at the index time were appropriate and adequate and as per the roster for the area the patient was cared for. The staffing levels would not have impacted on the ability to undertake neurological observations.”

Source location

2021-0239-Response-from-Aneurin-Bevan-University-Health-Board_Published
Page 1 · response
Published 15 July 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Complete an in-depth review of Emergency Department nurse staffing levels at Grange University Hospital, considering increased demand and relevant staffing guidance.

Verbatim wording from the response

“I thought it would be helpful to share that an in-depth review of nurse staffing levels for the Emergency Department (ED) at the Grange University Hospital was commissioned as a result of the early opening of the hospital and in light of increased patient demand. This has been undertaken by the”

Source location

2021-0239-Response-from-Aneurin-Bevan-University-Health-Board_Published
Page 1 · response
Published 15 July 2021

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Nurse staffing levels were adequate and did not prevent neurological observations.

Verbatim wording from the response

“Following receipt of the Regulation 28 Report a review of the nurse staffing levels was undertaken by the Senior Nurse Manager of the Emergency Department. I can confirm nurse staffing levels at the index time were appropriate and adequate and as per the roster for the area the patient was cared for. The staffing levels would not have impacted on the ability to undertake neurological observations.”

Source location

2021-0239-Response-from-Aneurin-Bevan-University-Health-Board_Published
Page 1 · response
Published 15 July 2021

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026